| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
355 |
355 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
285 |
285 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
229 |
229 |
$6K |
| D1351 |
Sealant - per tooth |
106 |
35 |
$5K |
| D1110 |
Prophylaxis - adult |
107 |
107 |
$5K |
| D0274 |
Bitewings - four radiographic images |
227 |
227 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
153 |
153 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
442 |
442 |
$4K |
| D1206 |
Topical application of fluoride varnish |
122 |
122 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
495 |
494 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
34 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
15 |
$1K |
| D0330 |
Panoramic radiographic image |
60 |
60 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
13 |
$850.90 |
| D0140 |
Limited oral evaluation - problem focused |
39 |
39 |
$745.68 |
| D0272 |
Bitewings - two radiographic images |
70 |
70 |
$727.36 |